Thoracolumbar Fratures R1: 胡 家 瑞 指 导 老 师 : 吴 轲 主 任

Transcription

1 Thoracolumbar Fratures R1: 胡 家 瑞 指 导 老 师 : 吴 轲 主 任

2 Patient Data Name: 苏 XX Gender: Female Age:47 years old Admission date:

3 Chief complaint Fell down from meter tree and lead to lumbosacral region pain.

4 Present illness , she fell from meter tree,, felt lumbosacral region pain, can t walk. She was brought to our ER for help. Severe pain with limited ROM was noted. No dizziness nausea and vomiting fecal and urine incontinence.

5 Physical examination Tenderness of the lower back. Hip ROM mormal,no paresthesia. Bilateral dorsalis pedis artery pulsatile well. Bilateral SLRT(-)

6 Lumbar A-P & Lateral view

7 Pelvis A-P view

8 CT

9 Radiology Finding 1. L2Burst fracture 2. Thoracolumbar degeneration

10 Primary Diagnosis L2Burst fracture

11 Treatment 1. Bed Rest 2. analgesics( NSAID) drugs and baclofen used. 3. Thoracolumbar fracture open reduction and internal fixation

12 Treatment MP(methylprednisolone ) 治 疗 : SCI(Spine cord injury) 病 患 伤 后 内 8 小 时 使 用 30mg/kg iv in mg/kg/h keep run for 23h

13 Post operation

14 胸 腰 椎 骨 折 Thoracolumbar Fractures Discussion

15 Incidence 1. The rate of spinal fractures in a serious motor vehicle accident is 5-6%. 5 2.Injuries are most common in patients years of age and least common in persons younger than 18 years. 3.In young adults, fractures are commonly associated with multisystemic blunt trauma. 4. Among a sample of earthquake victims multilevel spinal injuries occurred in nearly 30%. 5.L1, L2, and T12 levels are most frequently injured. 6.Compression fractures are the most typical injury in the lumbar spine. The area of the lumbar spine most often injured is the thoracolumbar junction.

16 Mortality/Morbidity The primary morbidity in most patients is pain.spinal pain may be seen in patients with acute fractures. Other common forms of morbidity are lower extremity weakness or paralysis. Mortality in patients with lumbar spine fractures is primarily the result of associated injuries to the spleen, liver, aorta, and pelvis. Delayed mortality may be associated with urinary tract infections if the injury resulted in a neurotropic dysfunction of bladder control.

17 Race Bone density may be greater in blacks than in other races. Compression fractures in elderly women are more common in whites than in blacks. Postmenopausal estrogen use is associated with an increased likelihood of back pain and impaired back function in elderly white women. Sex Young males participate in at-risk behaviors and have more accidents. The occupational risk of a fall from a great height is greater among men than women. Compression fractures are more common among older women than other individuals

18 Clinical evaluation Fractures are often the result of high-energy trauma. Patient has been involved in an accident and is complaining of back pain. Any tenderness elicited will then pinpoint the location of the lesion precisely. Subcutaneous haematoma,, or even transverse stretch marks, are suggestive of a lesion caused by distraction of the posterior ligamentous structures. A full and systematic neurological examination should be carried out. It should noted that fractures of the thoracolumbar junction and the lumbar spine is reflex ileus related to a haematoma around the fracture; this may be mimicking or masking an intra-abdominal abdominal or a retroperitoneal lesion.

19 Dermatomal Sensory Testing

20 Reflex Examination

21 Classification of Spinal Cord injury Many Grading Systems Impairment Based Frankel ASIA Yale Motor Index Function Based Modified Barthel Index

22 Grading of Spinal Cord Injury

23 Grading of Spinal Cord Injury

24 Complete VS Incomplete Complete No function below level of injury Absence of sensation and voluntary movement in S4/5 distribution Incomplete Preservation of sensation in S4/5 distribution and voluntary control of anal sphincter

25 Incomplete cord lesion Determined by anatomic location of tissue injury Must understand cord anatomy Predictably pattern based on involvement

26 Incomplete cord lesion

27 Incomplete cord lesion

28 Cauda Equina Syndrome Cord ends L1/2 disc space Lower motor neuron axons Perianal anesthesia, sphincter and bladder dysfunction

29 Lumbar and Sacral Motor Root Function

30 Functions of the Spine Structural support and balance for upright posture

31 Functions of the Spine Flexibility of motion in six degrees of freedom Flexion and Left and Right ExtensionSide Bending Left and Right Rotation

32 Vertebral Structures Pedicle notches Intervertebral foramen Nerve roots exit Slight Notch Deep Notch Intervertebral Foramen

33 Spinal Stability

34 Mechanical Stability 3-column theory (Denis 83) middle = posterior ½ VB, posterior disc, post longitudinal ligment 2-column theory (Holdsworth, Holdsworth, 53) anterior= VB, disc, ALL, PLL posterior= neural arch, Post ligment complex

35 Denis: MIDDLE COLUMN is key to stability The columns can fail individually or in combination by 4 basic mechanisms of injury : Compression Distraction Rotation Shear

36 Stable v.s Unstable injury three column system is helpful in evaluating spinal injuries & determining which are stable or unstable. at the thoracolumbar junction, more than 20 degree of kyphosis indicates an unstable fracture. thoracolumbar injuries will be stable if middle column is intact, & will be unstable if disrupted. w/ the exception of upper thoracic spine injuries; - above T8, injury may disrupt middle column, but fracture will still be stable manner if sternum and ribs in area of injury are OK; - chest wall tends to splint the injury site, and if chest wall is unstable the injury will be unstable;

37 Classification (Denis)

38

39 Compression fracture Injures the anterior column due to anterior or lateral flexion Middle column remains intact Posterior column usually intact, but may fail in tension XRay : decreased height of anterior vertebral body, posterior body height normal Amount of anterior compression less than 40% of posterior body height Clinically stable, neurologic loss is rare 4 types Involvement of both endplates Superior endplate only Inferior endplate only Buckling of anterior cortex with both endplates intact

40 Compression Fractures Compression fractures rarely require surgery Surgery is indicated if PLC disrupted Relative indications for surgery single level lumbar VB height loss >50 % single level thoracic VB height loss >30 % combined multi-level level height loss >50 % relative segmental or combined kyphosis >30 º

41 Treatment Symptomatic, usually stable Hyperextension exercises Avoid compression loads for 3 months If loss of vertebral height is more than 50%, angulation more than 20 degrees, or there is multiple adjacent compression fractures, is potentially instable Thus mobilise as above and monitor for progression of deformity. If progresses, perform ORIF A vertebral compression fracture wedged more than 40% of normal height usually needs a posterior stabilisation procedure, as these fractures may compress further, even after 3 months

42 Burst Essential feature is disruption of the middle column with varying degrees of retropulsion into the neural canal XRay : spreading of posterior elements Clinically if posterior elements are involved, there is 50% chance of neurologic injury Columns :Anterior : compression;middle : compression; Posterior : none 5 types Fracture of both end plates seen in low lumbar region Fracture of the superior endplate Fracture of inferior endplate Burst rotation due to axial load and rotation Burst lateral flexion due to axial load and lateral flexion

43 Treatment Nonoperative : Patients with no neural involvement do well in long term with no neurologic deterioration and little residual back pain Operative indications : In thoracic spine, Kyphosis more than 40 degrees associated with progression of deformity Where neural injury present Loss of vertebral height of more than 50% Angulation more than 20 degrees Canal compromise more than 40% In 75% adequate canal decompression can be obtained by posterior instrumentation alone Perform post-operative operative CT : in the situation that residual canal compromise is more than 25% with an incomplete lesion, consider anterior decompression

44 Flexion-distraction (Seatbelt type) May be purely bony, i.e. Chance fracture, purely ligamentous or mixed XRay : widening of interspinous distance Clinically : neurologic deficit is rare Columns Anterior : none or compression Middle : distraction Posterior : distraction Treatment : posterior stabilisation with decompression

45 Fracture-dislocation All 3 columns fail under compression, tension, rotation or shear leading to subluxation or dislocation Columns Anterior : compression/ rotation/ shear Middle : distraction/ rotation/ shear Posterior : distraction/ rotation/ shear Types 1. Flexion-rotation 2. Shear 3. Flexion distraction

46 Treatment Associated with severe neurologic damage Goals : realign the spinal column and stabilise spine to allow early mobilisation Early mobilisation reduces morbidity and mortality and allows earlier return to the community

47 Decompression Spinal realignment often decompresses prone positioning on OR table O.R.I.F. O.R.I.F. locked locked facets: open reduction by resection of articular processes

48 Posterior constructs provide stability after re-alignment little chance for neuro recovery Rarely require anterior decompression/ reconstruction